Transition Program Success

When a child with autism is no longer of school age, it is vital for them to have fundamental transition skills in their repertoire. These skills will aid a child with autism to successfully transition from a day school setting to a vocational/ day habilitation setting. Some of these skills include, but are definitely not limited to, delivering supplies, packaging materials, sweeping, vacuuming, making small snacks, doing laundry, stapling, and stuffing envelopes.

Over the years at the Day School, the Transition Program has been a work of progress. While the basic transition skills were taught, there was never a clear focus as to what the students were accomplishing or a true unity of the teachers in the transition classrooms. It is not that the teachers didn’t work together or that the students weren’t being taught in the right fashion, but the Transition Program of today is a lot more specific and focused than the one of yesterday. If you came to visit the Day School Transition Program today, you would see a completely different program.

In the program today, there are four classrooms, each designed with a different function. The rooms serve the following purposes: a one bedroom apartment, an office, a custodial skills room, and an academic classroom. Throughout the school day, each classroom spends an hour in each different physical classroom. In addition, each classroom is responsible for different daily activities throughout the school building. These activities include collecting clothes and taking them to the laundry, delivering spray bottles, preparing Jello and other snacks, picking up bottles and taking them to the store to be recycled, and sweeping, mopping, and vacuuming throughout the school day. The four teachers work as a cohesive team to make sure that all these activities are completed and that each classroom functions as parts of a whole.

Just describing the program is not enough to illustrate how great this program has become. It is important to describe certain students and what they are now doing as part of the transition program. In previous years, Shane had been on a behavior treatment plan that just involved him getting to sit appropriately without screaming or picking at his face throughout the school day. Currently, Shane is delivering spray bottles throughout the school building (with some verbal prompting), sweeping independently, and recycling. Clara had engaged in aggressive behaviors multiple times throughout the school day and had been difficult to engage in academic work. She is now preparing Jello with only minimal prompting, asking for paper to recycle, and taking attendance for lunch. Her aggressive behaviors have also dramatically decreased and she is easily engaged in these transition activities. The students described are just a sample of what the new transition program has done for children with autism.

The current Transition Program has been flourishing and it is only the first month of school. The program has only room for growth and more opportunities for these students to succeed.

Learning to Tolerate Preferred Activities

Finishing playing with a preferred item before you are ready to end is never a pleasant experience, but for our students with limited speech, it can be a frustrating, overwhelming one. At the Day School we often encounter students who have difficulty tolerating the removal of their preferred items, or demonstrate difficulty waiting for those items to be delivered. For one particular student, this posed a great problem, and impeded his ability to work and participate in classroom activities with peers.

Johnny was a student who initially preferred creative activities of cutting, coloring, and pasting. His love of art led to many difficult problem behaviors, primarily when asked to end the activity. His behavior escalated, both at home and in school, to unmanageable levels for one adult to handle. Specifically, the student would become extremely agitated and frustrated when denied access to paper and cartoon cut outs.

Initially, we decided to teach Johnny to play appropriately with the art materials. Once this was achieved, we began to slowly intervene throughout the play session by requesting for a crayon or a marker and immediately returning it. This continued until we were able to request for a crayon and hold on to it for 30 seconds before being returned. At this time Johnny was allowed free access to these materials, and we knew that we needed to implement a way for him to request them, and then tolerate a delay in receiving them. This would then mimic the natural environment more accurately. We began with conditioning a token system, which would eventually be used throughout programming. This would create a system where Johnny would complete a number of trials before being provided access to the terminal reinforcer. Additionally, every time Johnny requested for an item, we would delay the time between the request and when the item was received. This time interval was increased systematically until Johnny was waiting appropriately for forty five minutes before receiving his preferred item. This was ideal, but still not solving one major obstacle: What happens when the toy Johnny wants is not available? Or the printer is out of ink and he cannot print a cartoon character? These are obstacles families face on a daily basis, and just increasing the interval he had to wait would not be enough.

So, our final objective was to teach Johnny to tolerate an alternative choice option, following a request. We started off with offering a highly preferred alternative item immediately following the initial request. If Johnny requested Play Dough, we offered Moon Sand. If he requested a crayon, we offered a marker. If he accepted the item and played appropriately for five seconds, we would immediately offer the originally requested item. This strategy aimed to teach Johnny that if the requested item was unavailable, he could still have access to other items, and then when the item became available, he would receive it. Throughout the following months, we began to offer items not as close in form or function as the originally requested item. We also increased the amount of time that elapsed before Johnny gained access to the original item.

Today, Johnny is able to work for long durations of time without receiving constant access to his preferred items. He now tolerates delays in receiving items, and allows other students to interact with his toys. He is able to tolerate alternative items when the items he originally requested are being used by other students or unavailable. Working towards meeting these types of goals is a long term project, but with dedication and perseverance they can be achieved.

QSAC’s Sibling Support Group: A Success Story

by Anne Denning, MA, BCBA, Director of Training

QSAC offered its sixth Sibling Support Group this summer which had the largest turn out of all the previous summer sessions. There were a total of 13 siblings in attendance. This was a group experience offered to siblings of QSAC students once a week for 5 weeks in the evenings. The Sibling Group was comprised of 2 groups, which were separated according to age. The age range was from 5 to 16 years old.

While the siblings were in their groups, the parents were in support group with school social worker Madelyn Wolfin, and the QSAC students were in respite. This set up allowed the entire family to participate.

QSAC’s Sibling Support Group provided an opportunity for brothers and sisters of children with autism to obtain peer support and education within a recreational context.

The group offered these children a chance to meet with each other in a fun, relaxing and supportive environment. It was a wonderful experience devoted to the sometimes forgotten or "lost in the shuffle" siblings of those with autism.

The Sibling Group shared information and discussion activities, which proved to be just as fun and rewarding for the facilitators as it was for the participants.

Siblings had special concerns and feelings. They needed acknowledgement of their concerns and feelings, and help in dealing with their feelings and emotions. Weekly discussions focused on important topics such as understanding autism, building self-esteem and building stronger sibling relationships and support networks.

Brothers and sisters had much to offer one another since they were given the chance. The group facilitators were Madelyn Wolfin, Preschool and Day School Social Worker, QSAC’s Director of Training, Anne Denning, QSAC Director the After School Program, Dita Ruc, QSAC’s Assistant Director of the After School Program, Rocio Chavez and QSAC’s Director of Family Services, Carolyn Abbott

A special thank you to all the families who participated in the Sibling Group - without them this would not have been possible!

New Venue and Performance Dates for Got Talent 2!

We have a new venue and three new live performance dates for Got Talent 2. The event will now take place at The Midtown Theater at 163 West 46th Street.

Join us on TUESDAY nights: October 11, October 25 and November 8 with the Grand Finale on November 29th.

We're still accepting submissions!
If you think you've got what it takes, complete our online application form at www.qsac.com/talent

Interventions for Individuals on the Autism Spectrum and How Best to Evaluate Their Effectiveness

Throughout the years and currently, there have been many fad treatments which arise claiming to have significant effects on individuals diagnosed with an autism spectrum disorder; however, claiming to be effective and empirically demonstrating such effects are two different things. The following article discusses what to look for when evaluating effective treatments.

Written by Bob LaRue, Ph.D., BCBA-D, Associate Director of Behavioral and Research Services Douglass Developmental Disabilities Center, Rutgers University & Amy Hansford, B.A.,

Autism is a complex disorder characterized by significant deficits in social reciprocity and communicative ability as well as the presence of repetitive behavior/restricted interests. Given the heterogeneous nature of autism, many interventions have emerged with claims of effectiveness. Applied Behavior Analysis (ABA), sensory integration, specialized diets (e.g., gluten and/or casein free diets), pharmacological interventions (e.g., Risperdal), and mercury detoxification procedures are among the most commonly-used interventions with learners on the autism spectrum. However, with the exception of ABA, many of these treatments persist in the absence of scientific data supporting their use. This absence of data is particularly problematic for parents and practitioners who are trying to provide the best possible intervention for their learners with autism. The prospect of selecting an appropriate treatment for autism can be overwhelming for anyone with the vast amount of conflicting information available.

Most experts agree that the best first line of treatment is an intensive, coordinated program of special education and behavior management. Developmentally appropriate intervention programs generally include a language-based curriculum, systematic intervention to improve communication and social skills and a structured plan to address maladaptive behavior. Behavioral intervention strategies, derived from ABA, have the most empirical support for their use. In addition, ABA has been endorsed by the U.S. Surgeon General (1999), National Institutes of Health (NIH) and the National Standards Report published by the National Autism Center (2009).

Non-behavioral treatments can generally be divided into two main categories: biological and non-biological interventions. Biological interventions include treatments such as Hyperbaric Oxygen Therapy (HbOT), vitamin therapy, specialized diets (e.g., gluten-casein free diets, Feingold diet) and psychotropic medication. With the exception of psychotropic medication research, sound empirical evidence supporting the effectiveness of these interventions for learners with autism is sparse.

Of note, several studies have shown that certain psychotropic medications (e.g., Risperdal) can decrease some aberrant behavior (e.g., impulsivity, aggression). Non-biological interventions include treatments such as Sensory Integration Therapy (SIT), Facilitated Communication and Craniosacral Therapy.

While behavioral intervention is a good, empirically-supported starting point, it would not necessarily preclude the use of alternative interventions, if the use of such alternative interventions was carried out in a careful manner using operational definitions of targets, continuous data collection and a strong design to assess efficacy. Rejecting other types of intervention without understanding and evaluating them is problematic for several reasons. First, the absence of supporting evidence is not the same as evidence against an intervention. One of the main problems with the new and emerging treatments for autism is that limited research has been done to either validate or invalidate these interventions. Complicating this further is the fact that scientific journals do not typically publish negative research findings. In other words, research indicating that particular treatments are not effective may not be accepted for publication because of a journal‘s bias to only print positive findings. Another complicating factor is the individual variability of response to different treatments for autism. As mentioned previously, autism is a complex disorder with a variety of different etiologies that may affect response to treatment. Strategies may work for some learners and not others. It is important for practitioners to approach the intervention process with an objective mind. Rather than dismissing alternative approaches to intervention, practitioners should take the opportunity to study these interventions and systematically eliminate components that are not effective. Unfortunately, alternative interventions are often carried out in an unsystematic manner which precludes a valid assessment of outcome.

Alternative therapies are going to be part of the autism treatment landscape for years to come. It is the responsibility of both parents and practitioners to become informed consumers of autism services. It is important to critically review the validity of proposed treatments, read the literature (peer-reviewed articles rather than testimonials or anecdotal reports) and look for scientific evidence of benefit, potential health risk, and financial or time cost of all treatments. While the temptation to "leave no stone unturned" may seem appealing, wasting precious time with ineffective interventions may prevent learners from maximizing their potential.

In addition to educating themselves about alternative interventions, practitioners and parents should critically evaluate the effectiveness of the intervention process. It is often the case that people do not use systematic designs to assess the effectiveness of alternative treatments. Implementing treatments in a reversal (ABAB) design or multi-element designs can provide valuable information regarding the efficacy of treatments. Furthermore, a variety of behavioral assessment and measurement procedures, such as observational data coding, preference and reinforcer assessments, and functional analyses, can be viable ways to evaluate the effects of these interventions. Using behavioral measures for the purpose of evaluation can allow for testing some of these alternative interventions to determine if there is a clinically significant response. Such procedures could allow parents and practitioners to only use interventions that are effective and discontinue components that are ineffective. These measures can be used to determine if treatment effects generalize to different settings and also to monitor the occurrence of side effects.

In summary, there exists a wide variety of behavioral and non-behavioral interventions for learners on the autism spectrum. Some of these interventions have garnered empirical support (i.e., ABA and some psychotropic medications) while many have not been studied thoroughly enough to validate the effectiveness for use with learners with autism. Unfortunately, many treatments that are ineffective persist because they often promise miraculous results and are easy to use. The best solution is for parents and practitioners to educate themselves regarding these alternative therapies and critically evaluate the effectiveness of these interventions. In doing so, parents and practitioners can ensure the best possible intervention for their learners, prevent time from being wasted and can ultimately help others through the process by sharing their findings with others.

Universal Screening to Improve Early Detection of Autism

On August 15, 2011, NPR radio station ran an interesting research report about the childhood risk of developing autism when a child has a sibling with the disorder. Dr. Ozonoff of the University of California, Davis, who led the research, emphasizes the importance for pediatricians of being aware that “if they have a little boy in their practice who has an older sibling [with autism], that child's risk is 25 times higher than another infant in their practice."

Parents, pediatricians, educators, psychologists, and researchers recognize the importance of improving early detection of individuals at risk of autism spectrum disorders. Early detection by using the appropriate tool strategies will lead to early diagnosis, treatment and improved outcomes. The diagnosis before 2 years of age is still not accurate. Some children diagnosed at risk of autism spectrum disorders show the symptom domains at age of 4 (AAP. 2007).

Early detection and intervention may lead to good prognosis in terms of improving language, social interaction, adaptive behavior functioning, and maladaptive behaviors. In order to have early detection, the American Association of Pediatrics (AAP, 2007) recommends performing dual screening at age of 18 and 24 months. Some research studies suggest that dual screening has demonstrated better sensitivity because some children may pass the screening at age of 18 months, but then are detected at the age of 24 months. Some researchers hypothesize that this phenomenon may be due to regression or simply because the child develops the symptoms later (Hollander, et al., 2011).

We found also some disparities in the treatment of individual with autism spectrum disorder. According to the CDC (2006), minority children, especially Hispanic and low social economic status or children with less severe symptom domains may experience some delay in treatment or unequal delivery of services (Zwaigenbaum et al., 2007).

Research studies have found disparities in the screening process based on ethnicity, especially when comparing screening of Hispanics with non-Hispanics. Among the barriers to standard ASD pediatric screening were health system and practice related barriers, (time, reimbursement, infrastructure), family related barriers (no- shows, other concerns, relationship with doctor, providing information to the doctor), and provider related barriers (belief in efficacy of screening, early diagnosis, early treatment, belief that formal screening is unnecessary) (Fein, 2011). For instance, the reimbursement to providers for ASD screening vary among insurances, and in general is not mandated (Dumont- Mathieu, 2008).

According to Dr. Fein, inconsistency, disparities, and barriers in the screening process for early detection and treatment of ASD justify the implementation of a “universal screening for autism.” In addition, screening tools in multiple languages are needed to minimize the disparities. However, some researchers are opposed to a universal screening for autism, stating that “we do not have enough sound evidence to support the implementation of a routine population-based screening program for autism (Al-Qabandi, Gorter & Rosenbaum, 2011).

There is yet to be a clear consensus on whether broad­band screening will suffice as a first-line screening or whether two autism screens are needed to better detect early signs of Autism Spectrum disorder. This author agrees with the American Association of Pediatrics (AAP) that we should continue screening children at every medical visit, use at least 1 screening tool consistently before 18 months, and consider screening also at 24 months to identify social and communication deficiencies (AAP, 2007).

Some of best screening tools for early detection include the Clinical judgment, Autism Diagnostic Observation Schedule (ADOS), Childhood Autism Rating Scale (CARS), and the Modified Checklist for Autism in Toddlers (M-CHAT). M-CHAT, especially, has been shown to accurately detect children with autism at an early age and can help minimize the disparities and barrier associated with ethnicity, education, and social economic status (Hollander, et al., 2011). The M-CHAT is available free online for parents, caregivers, and health professionals (www.m-chat.org)

Autism Risk for Siblings Higher Than Expected

Parents who have a child with autism have about a 1 in 5 chance of having a second child with autism spectrum disorder (ASD), a far greater risk than previously believed, new research shows.

The study published on August 15, 2011 in the journal Pediatrics is the largest study to date focusing on the risks of autism among siblings.

Researchers conducted a longitudinal study of 664 infants with an older biological sibling with ASD and followed them from early in life to 36 months, when they were classified as having or not having ASD.

A total of 18.7% of the infants developed ASD. There was an almost threefold increase in risk for male siblings and an additional twofold increase in risk if there was more than one older affected sibling.

This study demonstrates that the sibling recurrence risk of autism spectrum disorder is substantially higher than previous estimates of between 3-10%. This elevated risk has important implications for infant screening and genetic counseling. Additionally, this study highlights the importance of routine surveillance and rapid referral for infant siblings of children with ASD. Given the higher-than expected recurrence rates, particularly for male infants and multiplex families, it is critical that primary care professionals closely monitor the development of infants who have older siblings with ASD.